We are nearly there. Close the Gap for Vision

We are nearly there Close the Gap for Vision

Executive summary Australia is on the verge of closing the gap in Indigenous eye health Elimination of trachoma Sight restoration for ~4,000 Indigenous Australians with cataract each year Blindness prevention in ~3,000 Indigenous Australians with diabetic retinopathy each year Sight enablement for ~4,500 Indigenous Australians each year by giving them glasses... The Roadmap to Close the Gap for Vision is a standout example of a program that has been successful in its progress towards closing the Indigenous health gap Remarkable results have been achieved in only a few years and the Roadmap recommendations are well on the way to being fully implemented Progress in Indigenous eye health has long been a challenge, making the success of this collaborative work even more remarkable This work has undergone rigorous scientific process and has a strong evidence base It has been strongly supported by local communities and organisations, including leading peak bodies and philanthropic organisations... To ensure we reach the finish line, we can t afford to take our foot off the accelerator While progress has been made, the recommendations need to be fully implemented to close the remaining gaps We are at risk of a bounce back in progress if funding is not continued we have seen this happen before... Continuing the program for four years, with adequate funding, will close the gap in the four areas of eye health that account for 94% of vision loss in Indigenous Australians ~$0m in funding is needed each year for four years; ~$0m is a continuation of current funding and ~$0m is a new commitment The additional ~$0m in funding will ensure the remaining recommendations are fully implemented, with ongoing separate funding not required after 00 Lessons from Indigenous eye health offer guidance on success for other Indigenous health settings

Contents Australia is on the verge of closing the gap in Indigenous eye health The Roadmap to Close the Gap for Vision is a standout example of a program that has been successful in its progress towards closing the Indigenous health gap To ensure we reach the finish line, we can t afford to take our foot off the accelerator Continuing the program for four years, with adequate funding, will close the gap in the four areas of eye health that account for 94% of vision loss in Indigenous Australians 3

Australia is on the verge of closing the gap in Indigenous eye health Condition 00 Goal Trachoma Elimination of trachoma... Cataract Sight restoration for ~4,000 Indigenous Australians with cataract each year... Diabetic retinopathy Blindness prevention in ~3,000 Indigenous Australians with diabetic retinopathy each year... Refractive error Sight enablement for ~4,500 Indigenous Australians each year by giving them glasses, Defined as: (i) a prevalence of trachomatous trichiasis unknown to the health system of less than case per 000 total population; and (ii) a prevalence of trachomatous inflammation-follicular in children aged between 9 years of less than 5%, in each formerly endemic district (WHO) SOURCE: National Indigenous Eye Health Survey 008, The Roadmap to Close the Gap for Vision 0 via online calculator 5

Remarkable results have been achieved in only a few years Blindness rates The rate of blindness in Indigenous Australians has gone from 6x (008) to 3x (06) the rate seen in non-indigenous Australians Trachoma The prevalence of trachoma in Indigenous children has gone from % (008) to 4.6% (05) after implementation of WHO s SAFE Strategy 6x Indigenous Australians non-indigenous Australians % Prevalence of trachoma 3x 4.6% 008 06 008 05, World Health Organisation, Strategy to eliminate trachoma encapsulated by the acronym SAFE : Surgery for advanced disease, Antibiotics to clear C. trachomatis infection, and Facial cleanliness and Environmental improvement to reduce transmission SOURCE: National Indigenous Eye Health Survey 008, National Eye Health Survey 06, National Trachoma Surveillance and Reporting Unit (NTSRU) reports 008 and 05 7

and the Roadmap recommendations are well on the way to being fully implemented Roadmap rollout of 4 recommendations have been fully implemented All are on track to be implemented by 00... Specific regional activities Reach 8 regions, making up over 40% of the Indigenous population, have begun implementing the specific Roadmap recommendations In addition, progress has been made and planning is underway in every state and territory... Example The Grampians in Victoria is an example of a region that has been successful in improving eye health outcomes: 5-fold increase in optometrist services from February 05 0% absolute increase in annual diabetic eye checks from March to August 06 Cataract surgery waiting list reduced to zero from March to June 06 58% increase in subsidised spectacles 8, with appropriate funding commitment SOURCE: 06 Annual Update on the Implementation of The Roadmap to Close the Gap for Vision, Closing the Gap in Indigenous Eye Health: Regional Implementation of the Roadmap to Close the Gap for Vision (Jatkar et al., 06)

Progress in Indigenous eye health has long been a challenge, making the success of this collaborative work even more remarkable Trachoma prevalence % 35 Trachoma prevalence Blindness Relative blindness of Indigenous pop (multiple of non-indigenous pop) 5x 30 5 x 0 9x 5 6x 0 5 3x 980 National Trachoma & Eye Health program; recommended ongoing specialist visits to rural areas Trachoma and Eye Health Report provided high level recommendations on resources, governance and funding National Trachoma and Eye Health Conference implemented a version of WHO grading system for Trachoma 990 The National 68 community- Aboriginal Health controlled AHS & Strategy 44 clinics set up with recommendations Commonwealth included community support through control & participation, ATSIC focus on public health, integration of primary & specialist programs ATSIC was founded and decentralised decision-making & funding Indigenous Eye Health Review (IEH) gave recommendations on models of eye care delivery 000 National Aboriginal and Torres Strait Islander Eye Health (NATSIEH) Program set up to implement IEH Review recommendations by increasing workforce capacity & infrastructure, establishing REHC 3 positions, and providing ophthalmic equipment National Trachoma Surveillance & Reporting Unit established Review of the NATSIEH program recommendations included integrated delivery of eye program into primary care, global funding at 4 ACCHS level, linking with mainstream providers 00 National Indigenous Eye Health Survey 008 The Roadmap to Close the Gap for Vision launched Australian government committed to and funded the elimination of trachoma, Aboriginal and Torres Strait Islander Commission, Aboriginal Health Services 3, Regional Eye Health Coordinator 4, Aboriginal Community Controlled Health Services SOURCE: The Roadmap to Close the Gap for Vision Full Report 0, Eye Health in Aboriginal and Torres Strait Islander Communities 997, National Indigenous Eye Health Survey 008, National Eye Health Survey 06, NTSRU Report (00), NTSRU Report (05) 9

This work has undergone rigorous scientific process and has a strong evidence base 3 National Indigenous Eye Health Survey 008 defined the size of the problem,883 people, randomised sample, stratified by remoteness area (urban to remote)... 4 The extent of existing eye services and remaining gaps were published in four documents, including Access to Eye Health Services Among Indigenous Australians... 5 6 The Roadmap to Close the Gap for Vision identified barriers to accessing care Published in 0 with 4 recommendations across 9 domains Used focus groups and field visits to identify barriers and assist in development of recommendations: 0 focus groups with 8 Indigenous community members 89 staff in field interviews across sites 86 people provided input through 3 stakeholder workshops 38 meetings with 75 people representing 56 stakeholder organisations... The Cost to Close the Gap for Vision defined costs to implement evidence-based policy Comprehensive costing model captured all direct medical and non-medical costs... Annual Updates on the Implementation of The Roadmap highlight progress on regional implementation 5 Annual Updates have been published that illustrate context, track process and health indicators, and track extent of implementation of the recommendations... Monitoring and reporting by external bodies: Process indicators to be reported annually by AIHW from 06 (e.g., cataract surgery rate) National Eye Health Survey 06, performed by CERA and Vision 00 Australia to report on prevalence of blindness and low vision in Indigenous and non-indigenous Australians 3 4 5 0, Australian Institute of Health and Welfare, Centre for Eye Research Australia SOURCE: The Roadmap to Close the Gap for Vision Full Report 0

It has been strongly supported by local communities and organisations Development and implementation Ongoing engagement Indigenous communities Aboriginal Health Services (AMS ) Board, CEO, Managers, Aboriginal Healthcare Workers Eye care service providers NACCHO, State 3 ACCHOs Regional eye health coordinators Visiting Ophthalmologists Visiting Optometrists Hospital staff Community health centres Local Divisions of General Practice Medicare Locals Primary Health Networks 4 NGOs Fred Hollows Foundation, Brien Holden Vision Institute, Vision 00 Australia Commonwealth and State Governments In the year to October 06: 0 Ministerial meetings 50 government department meetings 480 stakeholder meetings 3 national forums, Aboriginal Medical Service 3, Aboriginal Community Controlled Health Organisations, National Aboriginal Community Controlled Health Organisation 4, Non-governmental organisation SOURCE: The Roadmap to Close the Gap for Vision Full Report 0; Indigenous Eye Health, University of Melbourne

including leading peak bodies and philanthropic organisations Endorsement... Collaborators and many State, regional and local service providers... Supporters and several anonymous foundations and donors

While progress has been made, the recommendations need to be fully implemented to close the remaining gaps Condition Trachoma Cataract Diabetic retinopathy Refractive error What is at stake While rates of developing cataract are the same, in 008 the risk of blindness was x that of the non-indigenous population and the cataract surgery rate was 7x less than the national rate Progress Australia is the only high income country to still In 05, of 33 communities identified to be at have trachoma risk in 008: 69 are trachoma free 6 have a prevalence of 0-5% However, 40 communities still have trachoma: 4 have a prevalence of 5 to 0% 6 have a prevalence >0% ( hotspots )... The number of people with blindness from cataract has been reduced However, the 06 National Eye Health Survey Diabetic retinopathy is an irreversible cause of blindness Yet, only 0% of Indigenous Australians with diabetes received screening in 008 shows cataract remains the leading cause of blindness and surgery rates are still lower than for non-indigenous Australians... MBS item 35 will start to bridge this gap by providing funding for local providers to perform eye examinations commencing November 06 In addition, funding has been provided for screening equipment and training... Only 0% of Indigenous adults were wearing VOS funding has increased and a national glasses for distance vision compared to 56% of subsidised spectacle scheme is being investigated non-indigenous adults (008) The subsidised spectacle scheme in Victoria has provided over 7,000 spectacles since 03 Currently, for every $ spent on eye care, the return to the Australian economy is $0.90 Implementation of the Roadmap has been calculated to return $.50 for every additional $ spent 4, Medicare Benefits Schedule, Visiting Optometrists Scheme SOURCE: The Roadmap to Close the Gap for Vision Full Report 0, National Indigenous Eye Health Survey 008, National Eye Health Survey 06, Victorian Aboriginal Spectacles Subsidy Scheme Report September 06 (Australian College of Optometry), National Trachoma Surveillance and Reporting Unit (NTSRU) 06

We are at risk of a bounce back in progress if funding is not continued we have seen this happen before Reported Prevalence of Trachoma in Children 5% Children aged -9 years Children aged 5-9 years Projected rate 5-9 years 0% 5% 0% 5% Trachoma program funding ran out in June 03 and resolution of this funding was delayed until 04 This correlated with a bounce back in the prevalence rates of trachoma 0% 008 009 00 0 0 03 04 05, Projected prevalence rates adjust the measured prevalence rate for the underestimation that occurs by adhering to the revised 04 CDNA National guidelines for the public health management of trachoma in Australia. These revised guidelines for surveillance advise not to measure all communities that have high screening coverage and stability of prevalence rates for up to 3 years, 008 chosen as the start date due to reliable methods of data collection from this time forwards SOURCE: National Trachoma Surveillance and Reporting Unit (NTSRU) reports 008-05 5

~$0m in funding is needed each year for four years ~$0m is a continuation of current funding and ~$0m is a new commitment $m, 07 Additional funding required Continuation of current funding Total funding per annum Trachoma 5.0 0.8 5.8 $4.6m for screening and treatment $.m for health promotion National oversight 0. AIHW Annual reports To be reviewed by COAG Technical advice/support 0.8 Technical advice and support- IEH Focus on activity to Close the Gap for Vision 3 Diabetes equipment/ training Jurisdictional coordination Regional coordination.6.4.0 3.4 6.6 Provision of equipment and training in retinal 4 photography to support MBS item 35 5 6 $.m RHOF /VOS program funding $.m State fundholder (coordinating outreach services with the regions) Coordination within 3 Primary Health Networks Collection and monitoring of outcome data Local coordination.3 Local coordination and case management Total 9.6, Australian Institute of Health and Welfare 3, Indigenous Eye Health, University of Melbourne 5, Rural Health Outreach Fund, Council of Australian Governments 4, Medicare Benefits Schedule 6, Visiting Optometrists Scheme SOURCE: Predicted funding based on estimates from Vision 00 Australia and IEH, University of Melbourne 7

The additional ~$0m in funding will ensure the remaining recommendations are fully implemented, with ongoing separate funding not required after 00 Regional 8 Establish regional collaborative network of stakeholders Identify and support regional project officers to facilitate regional planning and reporting Undertake needs analysis comparing current eye care services with population-based needs Eye care support workforce needs identified to set up support staff roles Need for additional visiting eye care providers identified and funded through RHOF and VOS Identify patient support staff roles required to support the patient through the pathway of care Support chronic disease coordinators to coordinate surgery and the management of those with diabetes Develop regional service directory and referral protocols Introduce regional health promotion and awareness Establish regional data collection and monitoring systems Ensure local accountability and oversight State Commonwealth Implementation of effective and nationally consistent subsidised spectacle scheme Prioritisation of cataract surgery for Indigenous Australians Support regional planning and implementation State and national health outcomes and process indicators adopted and reported Establishment of bulk billing agreements for services funded by RHOF and VOS Funding of ophthalmology and optometry trainee visits Establish diabetic eye screening rates as a key performance indicator for Primary Health Networks Provide national oversight with review by COAG of AIHW reports on Indigenous eye health performance Security of funding for elimination of trachoma and adequate capped funding for implementation of the Roadmap, Rural Health Outreach Fund 3, Council of Australian Governments 3 4 SOURCE: 06 Annual Update on the Implementation of The Roadmap to Close the Gap for Vision, Visiting Optometrists Scheme 4, Australian Institute of Health and Welfare

Lessons from Indigenous Eye Health offer guidance on success for other Indigenous health settings Lesson Implications for other Indigenous health settings Template for integration The Roadmap provides a template for coordination and integration of health care for other conditions to meet population-based need including: Local planning and coordination of visiting specialists Integration of primary care and secondary specialist care... Widespread collaboration The Roadmap exemplifies the importance of establishing widespread collaboration and support: >80 local Indigenous communities and >550 people involved in its development Sector collaboration with 8 peak bodies and NGOs /philanthropic organisations Federal and jurisdictional government, and regional support... Monitoring & reporting Monitoring and reporting of performance is pivotal to ensure progress is maintained throughout program roll-out: Critical importance of national reporting, in this case by the AIHW, and national oversight Transparency of progress, through publication of annual reports, Non-governmental organisations, Australian Institute of Health and Welfare 9

Contact Professor Hugh R Taylor AC Indigenous Eye Health Melbourne School of Population and Global Health The University of Melbourne Level 5, 07 Bouverie St Carlton, Victoria 300 Phone: 03 8344 930 Email: h.taylor@unimelb.edu.au Website: www.iehu.unimelb.edu.au Melbourne School of Population and Global Health October 06